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General Internal Medicine

General Internal Medicine

Dr Ganesh Subramanian
Training Programme Director 
Based at Nottingham City Hospital
ganesh.subramanian@nuh.nhs.uk

Dr Patrick Davey
Training Programme Director
Based at Northampton General Hospital
patrick.davey@ngh.nhs.uk

Introduction

For those trainees wishing to specialise in general medicine, as well as their main specialty, the rotations in this region provide multifaceted exposure to all aspects of general medicine.  Trainees will gain their experience in a variety of ways, including seeing patients admitted as emergencies, patients with multiple disorders, patients referred to outpatient clinics for investigation and diagnosis, and patients referred by specialist services - as outpatients or urgent inpatient referrals.    The trainee builds on the core competences gained whilst in core medical training, as they acquire skills in the treatment and management of complex medical problems in both in-patient and out-patient settings. There is a greater emphasis on the need to understand the use of pharmacological agents and their complications in patients with multi-system disease. 
In addition to clinical exposure, there is an excellent regional programme of G(I)M teaching which takes the form of either whole day or afternoon teaching sessions throughout the year. 

Duration and Organisation of Training

The duration of specialist medical training in G(I)M is five years including CMT. Those seeking dual certification with another specialty will also need to fulfil the requirements of that specialty. Their programme will be extended to a minimum of 7 years (2 years CMT + 5 years HST) which include the specialty and 3 more years G(I)M).  Higher specialty training will provide experience both in district general hospitals (DGHs) and in teaching hospitals or other major centres with academic activity. Particular emphasis is put on the acquisition of practical skills which may be needed in the management of medical emergencies. 
The majority of trainees enter a programme which combines G(I)M with a specialty.

Year 1

The first year will usually be in a DGH.  The trainee will normally be expected to be on-call, on site and immediately available for at least 4 takes per month for acute unselected medical intake. The trainee should also undertake at least one outpatient clinic per week which must include a proportion of general medical patients and the ward follow-up clinic. This training may be undertaken on a firm or team which practices the trainee's intended main specialty or any other medical specialty. At the end of the year the trainee will have completed 3 years G(I)M, including the two years in CMT. Whilst the expectation is that the majority of trainees will spend the first year of HST in this way, it is not an absolute requirement. There may be circumstances in which this year of G(I)M could come later in the programme.

Later Years

The trainee should complete the remainder of HST in the chosen specialty, usually a further 4 years. During at least 2 of these years, dual training in G(I)M and the other specialty must take place in order to complete the minimum 5 years specialist training in G(I)M. Provided that such training has relevance to both specialties, it can count towards both CCTs. The overlapping training must include a commitment to acute unselected medical intake with responsibility for the continuing care of patients admitted as emergencies. If the trainee is not involved in the care of patients admitted to a CCU a secondment to such a unit must be arranged.  Experience in managing the acutely ill patient is essential.
This dual training period would normally take place in a period of 2 years towards the end of HST, but can be spread over the entire period providing the minimum requirements for G(I)M training at 'low intensity' are met. The trainee need not necessarily be resident for training purposes during the later years, although he/she must have personal 'hands-on' involvement in the acute care of at least 10 patients per 'take'.  Service commitments may require residence or more frequent take.

Geriatric Medicine

Up to one year of the training in G(I)M may be in suitable posts in Geriatric Medicine where an age-related admission policy applies. Such posts must provide experience of acute medical 'take' of patients unselected other than by age.  Units where acute G(I)M and Geriatric Medicine are integrated are fully acceptable for G(I)M training.  It is expected that the trainee would be responsible for the emergency care of at least 30 patients per month. It is important that these trainees undertake outpatient clinics encompassing adult patients of all ages over 2 years of their training.

Cardiology and Nephrology

In certain circumstances up to one year of G(I)M training may be in an approved post in Nephrology or Cardiology, provided that the SAC is satisfied that the training includes emergency care which is relevant to G(I)M and provided that the remaining training in G(I)M includes unselected medical intake at the higher level (at least 4 'takes' per month).

Supervision, Appraisal and Assessment

The Educational Supervisor

The programme to which the trainee is appointed will have named Educational Supervisors who will be on the Specialist Register in G(I)M and be actively involved in G(I)M clinical duties. One consultant within the same region will act as Programme Director to the trainee. The Educational Supervisor may not be the overall Programme Director. A single G(I)M trainer may supervise several trainees dependent upon local circumstances and needs.

ePortfolio

Access to individual ePortfolios will be granted to each trainee after their enrolment with JRCPTB.  The ePortfolio will contain the outcome of appraisals and assessments during training.  The ePortfolio will be used as evidence of progress in training at the annual G(I)M ARCP.

Assessment and Appraisal

There will be regular review of progress using the ePortfolio.  

Research

Periods of full-time research will not be permitted to count towards the requirements for G(I)M although they may do so in the other specialty in the case of joint programmes.  All periods of research require prospective approval of the Regional Postgraduate Dean and Specialty SAC by the trainee completing the relevant Out of Programme Experience form. For those undertaking an extended period of research after entering a programme and obtaining their training number, a limited amount of additional educational credit may be granted at the discretion of the SAC for clinical work undertaken in the course of research beyond the initial year.

Flexible Training

Trainees who are unable to work full-time are entitled to opt for flexible training programmes. Flexible trainees should undertake a pro rata share of the out of hours duties (including on-call and other out-of-hours commitments) required of their full-time colleagues in the same programme.  As is the case for full-time trainees, a period 'on take' may be less than 24 hours, provided an average of at least 10 patients are admitted per 'take'. For flexible trainees, there should be flexibility as to when in the training and how the trainee undertakes this on-call. The requirements are that by the end of HST the total number of 'takes' should be equivalent to those of a full-time trainee and that a proportion of the 'takes' should be undertaken in the last 2 years of training.  It should be noted that as CMT counts towards the minimum 5 years training for a CCT in G(I)M, the above rules also apply to flexible CMT posts which are to contribute to G(I)M higher training.

Acute Medicine Experience (throughout training in G(I)M)

Extensive experience in acute 'unselected' take is an essential part of training in G(I)M. There are several different patterns of organising acute take and it is strongly recommended that trainees gain exposure to more than one receiving system.  The trainee must have personal 'hands-on' involvement in the acute care of at least 10 patients per 'take.' Involvement in post-receiving rounds without active input to patient care during the take period does not count as a training experience. When 'on call', other service commitments must not be undertaken except under exceptional circumstances so that the trainee can concentrate their efforts on this crucial training and service area. There must be evidence of direct supervision of the activity of the more junior members of the 'on-take' team.

The Specialty Registrar supervising Acute Take

All medical patients admitted acutely should be seen and assessed within 24 hours by a senior physician who will usually be a consultant. Prior to being awarded a CCT a trainee should have had the opportunity to carry out post take ward rounds without the immediate supervision by a consultant. However, a consultant must be available on site for advice and remain responsible for the patient. The StR must previously have been demonstrated to have been competent. The SAC would recommend that StRs in their last year of G(I)M training are shadowed over a series of post take ward rounds by a training consultant, being allowed staged increases in responsibility, until they can be 'signed off' as competent to deliver the service without immediate supervision.  In addition, the trainee will be expected to have responsibility for on-going care. A minimum commitment of a personal 'post-take' ward round and continuing care of at least 10 general medical patients is required.

G(I)M at the 'Higher' Level

During G(I)M training in the early part of HST (normally year 1 in the DGH environment) the trainee will be required to undertake a minimum commitment of 4 takes per month of acute unselected emergency intake responsibilities. The trainee must be on site and immediately available and in the early part of training. An attachment of up to 6 months to a medical admissions ward or medical assessment unit can count as G(I)M at the higher level.

G(I)M at the 'Lower' Level

During G(I)M training towards the end of HST, which will usually be years 4-5 when dual training in the desired specialty is also occurring, 'on-take' commitment is required to be a minimum of 2 takes per month on average. When on 'take' the trainee must be immediately available to supervise the more junior medical staff.

Continuous G(I)M

In dual CCT programmes where G(I)M experience is spread evenly over the entire period of HST, 'on-take' commitment should be no less than 2 takes per month on average.

Minimum v Desirable G(I)M Experience

It can be seen that the minimum acceptable G(I)M training is one year of G(I)M at the higher level and two years G(I)M at the lower level.  Many trainees and educational supervisors will consider that this is insufficient to develop all the skills required and described in the curriculum. The amount of G(I)M experience necessary for each trainee will be based on individual circumstances. The SAC will not accept the training of an individual who has not fulfilled the minimum and will expect many trainees to have more than the minimum G(I)M exposure.

CCU experience

This is considered an essential part of acute G(I)M training. Normally this is part of the on-call responsibility and preferably the trainee should have first line responsibility for admissions to CCU. The minimum requirement, however, is that for one year of HST the trainee must have at least shared care of patients admitted with acute coronary syndromes and should have first line responsibility for all other acute cardiovascular problems. This may require, for example, joint ward rounds on the CCU between the trainee and the cardiologists. If this is not possible in a particular hospital or training programme then a 4 to 6 week period of secondment to CCU will be required. The training needs of the trainee with regards to CCU should be assessed at the initial meeting with the Educational Supervisor; progress should be assessed at subsequent meetings.

ITU or HDU Experience

Some experience in the care of critically ill patients is required.  It is not expected that all trainees will have detailed experience of ITU medicine although up to six months in an ITU post will count towards G(I)M training for those who have a particular interest. Experience in the care of the critically ill must be obtained over one year of the training programme and may be achieved in a number of ways: 

  • by being involved in the care of patients in a high dependency unit 
  • by being involved in the care of patients in a medical intensive care unit 
  • by admitting and sharing responsibility for patients admitted to a respiratory intensive care unit. 
  • A secondment for 4-6 weeks to an ITU should be organised

Training experience in Acute Medical Receiving Systems

Rationalisation of hospital services has meant that a number of hospitals no longer have A&E Departments. There are a number of different methods used to receive medical emergencies. Training is enhanced by being exposed to different systems of acute medical care. It would be inappropriate for a G(I)M trainee only to be exposed to acute receiving in a hospital which does not receive 999 calls or self-referred patients. At least one year of the minimum required acute takes during HST should take place in a system which is unselected, ie in a hospital which takes both GP and emergency referrals and patients who present 'off the street'.

Ongoing/Chronic Care

As well as acute emergency medicine, G(I)M training requires the development of expertise in ongoing care and the management of chronic diseases including preventative and public health medicine and the community aspects of disease.

Inpatient Responsibilities

The trainee will be expected to have direct supervisory responsibilities for the continuing care of at least 10 general medical inpatients. This will require at least one personal ward round per week and the supervision of junior members of the clinical team at other times. An additional ward round with the consultant each week is also expected.

Outpatient

The trainee is expected to have personal responsibility for the assessment and review of G(I)M outpatients in at least one consultant-led clinic per week for at least two years of HST. New patient referrals should be assessed by the trainee independently, but access to consultant opinion and supervision as necessary during the clinic is an essential requirement.  These cases may be seen as part of a specialist clinic but, as far as possible, should retain the 'flavour' of multi-system disorder or generic general medicine.  Ward 'follow-ups' are an essential part of G(I)M training particularly for the purposes of ongoing care commitment by the trainee. Some training programmes may use the 'follow-up' clinics as the principal vehicle for G(I)M outpatient experience, but this should also normally include exposure to new patient referrals. Where suitable general medical clinics are not available, it would be acceptable for trainees to have a planned rotation through a number of clinics in specialties other than their own.

Procedures

During training the trainee should acquire those practical skills which are needed in the management of medical emergencies, particularly those which occur out of normal working hours. Some exposure to these skills may have occurred during the period of CMT, but experience must be consolidated and competencies reviewed during HST. The procedures with which the trainee must be familiar and show competence in are listed in the syllabus.

Educational Training

For full details please see the Generic Curriculum available at http://www.jrcptb.org.uk/  
This training programme should be equivalent to 10 sessions per annum (one session = a half day or 3.5 hours). Trainees must attend at least 70% of sessions over the whole of the 5 year training programme (a minimum of 35 sessions in total) and a verified attendance record must be placed in the ePortfolio.   Where attendance at the regional teaching falls below these levels, credit may be given for attendance at equivalent external G(I)M-related courses such as those run by the Royal College of Physicians, at the discretion of the annual ARCP panel.

Management

All trainees will be required to undergo training in management. This will take the form of day-to-day involvement in the administration of the team or hospital and attendance at the management and leadership course at designated times during their training period.

Audit

Trainees will be expected to be actively involved in audit throughout their training and should have experience of running the unit's audit programme and presenting results of projects at audit meetings. They should also regularly attend other audit activities including journal clubs, X-ray conferences, pathology meetings etc.  Audit skills are generic and it is acceptable for trainees to gain experience through their subspecialty training.

Research

Research experience is considered an essential part of training. The form that this experience takes will vary between programmes. Trainees are encouraged to become involved in the research activity of the unit and may wish to take 'time out' periods for a specific period of research training leading to a higher degree. These 'time out' periods however cannot be counted towards training in G(I)M although this is usually acceptable (up to 1 year) for the other specialties.

Study Leave

G(I)M teaching days are mandatory and 70% attendance, wherever possible, is expected during the G(I)M years.  Trainees are expected to use their study leave entitlement to attend.  They are also encouraged to attend the annual RCP Update in Medicine conference as well.

Teaching

Trainees should become involved in the teaching activities of the unit. This may include teaching sessions for medical undergraduates, core medical trainees and other healthcare professionals. The exact nature and content of these sessions will vary between programmes and units.

Presentation and Communication Skills

Trainees should show evidence of the development of effective communication skills by taking part in formal case presentations and/or giving lectures/seminars to other staff or research/audit presentations at unit meetings.

Advanced Life Support

All trainees are expected to have completed successfully Resuscitation Council (UK) approved training in Advanced Life Support by the time of completion of Higher Specialty Training.

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