Training ANAESTHETISTS in Europe (UK)

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• Training ANAESTHETISTS in Europe (UK)

Monty G Mythen Portex Professor of Anaesthesia
and Critical Care. Director, Centre for
Anaesthesia, Critical Care and Pain Management.
University College London, UK
UCL
Centre for Anaesthesia
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USA and UK

• Two Great Countries Separated by a Common
  Language
• Oscar Wilde

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USA and UK

• Hey! Anesthesia!
• Duke Surgical Attending Circa 1995
• Excuse me please Dr Mythen. Frightfully sorry
  to disturb you but may I have a quick word about
  my patient
• UK Surgical Attending Circa 1995

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USA and UK

• Bed 12 ain lookin so peachy
• Duke Surgical Attending Circa 1995
• The Gentleman in bed 12 is demonstrating clear
  signs of tissue hypoperfusion (oliguria,
  acidosis, cool peripheries)
• UK Surgical Attending Circa 1995

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USA and UK

• Swan-im-up and do the dee-dot vee-dot thang
• Duke Surgical Attending Circa 1995
• Perhaps a tad more attention to Oxygen Delivery
  and Consumption might save the day
• UK Surgical Attending Circa 1995

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Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the
  O.R?
• Is it all economics?
• Challenges in training and future plans?
• Non-physician Anesthetists?

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Marathon des Sables

• Extreme endurance event- several hours/ day
• Thermal challenge
• Fluid loss
• Electrolyte imbalance
• Acute inflammatory response

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Marathon des Tables

• Extreme endurance event- several hours / days
• Thermal challenge
• Fluid loss
• Electrolyte imbalance
• Acute inflammatory response

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Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the
  O.R?
• Is it all economics?

YES BUT!
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Anesthesia Outside the OR?

• Critical Care 90 Anesthetists
• Pain Acute and Chronic 95 Anesthetists
• Pre-op evaluation
• Critical Care Outreach
• Management

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Funding in UK?

• National Health Service
• National Pay Scale
• No Billing!
• ALL Doctors paid same
• Term pension

• Private Practice
• Inflated hourly rates
• Direct Patient Billing
• Symbiotic relationship

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Anesthesia Outside the OR?

• Critical Care 90 Anesthetists
• Pain Acute and Chronic 95 Anesthetists
• Pre-op evaluation (replacing cardiology) Fit
  for Surgery
• Critical Care Outreach (PACU post-op care)
• Management

Doctors Doctor Nurses Nurse
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Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the
  O.R?
• Is it all economics?
• Challenges in training and future plans?
• Non-physician Anesthetists?

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Training changes in last decade 10 yrs ago

• Med Student 5-6 yr
• PRHO (no debts) 1 yr
• SHO (non-anesthesia) 1-4yr
• Reg. (3 exams FRCA) 4 yr
• Research (MD/PhD) 1-3 yr
• Senior Registrar 4 yr
• Consultant

96 hrs pre week undertime
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Funding in UK?

• National Health Service
• Service delivery by senior trainees
  (post-fellowship)
• Consultant led

• Private Practice
• Consultant delivered

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Training changes in last decade 10 years ago

• PRHO 1 yr
• SHO (non-anesthesia) 1-4yr
• SHO (Anesthesia) 2 yr
• Reg. (3 exams FRCA) 4 yr
• Research (MD/PhD) 1-3 yr
• Senior Registrar 4 yr
• Consultant

96 hrs pre week undertime
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Training changes in last decade - now

• PRHO (Modest Debt!) 1 yr
• SHO 1-4yr
• SpR 5 yr
• Consultant

48 hrs pre week OVERTIME! European Working
Time Directive EU equivalence in training
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Funding in UK?

• National Health Service
• Trainees
• Consultant delivered (48 h working week)

• Private Practice
• Consultant delivered

R.O.W
?
N.P.A
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Anaesthesia in Europe (UK)

• How convince Anesthesiologists to go outside the
  O.R?
• Is it all economics?
• Challenges in training and future plans?
• Non-physician Anesthetists?

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Non-Physician Anaestheitists in UK

• Can only work under Physicians
• Same as SHO (competent not post-fellowship
  NOT specialists)
• Training controlled by Royal College of
  Anaesthetists (27 months)
• NOT just Nurses
• Can not practice independently
• 1 Consultant 2 Assistants. Max 2 rooms (Private
  practice?)

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Non-Physician vs Physician

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

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Training?

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

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Post-Graduate Medical and Education Training
Board (PMETB)

• Single unifying framework for postgraduate
  medical education and training
• General and Special Medical Practice (Education
  and Qualifications) Order
• Approved by Parliament April 2003

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PMETB

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

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PMETB

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

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STA PMETB

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

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PMETB and Length of Training

• Does competency based training still need to be
  time based?
• European minimum recommended training time
• Does all training need to be completed before
  the award of a Certificate Completion Training?

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PMETB and the CCT

• CCTCCST
• Level of assessed competence in one or more
  areas of training
• What is the minimum training time for a CCT?
• The standard for the award of a CCT should be
  the same as that currently required for a CCST

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Foundation Years

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

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Foundation Years

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

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• Medical school Two Year Foundation
  Programme

Specialist or GP training
Provisional Registration GMC
Full Registration GMC


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F2 Curriculum

• Case mix suited to be taught by
• Critical Care
• AE
• Acute Medicine
• Anaesthesia
• Oct 2005

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F2 assessments

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

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Specialist Training

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

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Specialist Training

• PMETB sets the standards
• Apply direct from F2
• Competency based curriculum
• Defined levels of competence for service
  delivery
• End point is a CCT Accredited doctor

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

• Direct Path
• Broad-based Path - Common stem programme

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ICM,acute medicine, anaesthesia,AE

• Oct 2005

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• Oct 2005

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Seamless training

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

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Article 14 and Equivalence

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

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Article 14

• Country of origin is immaterial
• Considers training and experience from anywhere
• Ratio TE is unclear

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Equivalence

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

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145

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

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Nuffield Chair at Oxford University

• Any fool can give an Anaesthetic

• Yes, thats what worries me!

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Anaesthetic Grant Application
Dear Sirs Despite there never having been any
meaningful investment in Anaesthetic research,
Anaesthetics always work and are incredibly safe
(mortality lt 1100,000). Therefore, please give
us millions of Medical Research Council pounds
so that we may indulge ourselves in intellectual
frippery. Yours etc. p.s. if you ever need an
operation you will be safe with us
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Cardiology Grant!
Dear Sirs Despite having invested millions of
Medical Research Council Pounds in Cardiology,
heart disease remains the commonest killer in the
UK. Little or no progress has been made despite
having the most Professors and the biggest
departments. However, I have just noticed that
very few nematodes die from heart disease and we
have just decoded the human genome. Therefore,
please continue to give us millions of Medical
Research Council pounds so that we may continue
to indulge ourselves in intellectual
frippery. Yours etc. p.s you will probably die
from heart disease
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Hospital Mortality () following Major Surgery
and Intensive Care in UK 7/99 TO 01/00
ICNARC
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Patients in Hospital with Morbidity Following
Major Surgery at UCLH
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Survival of The Fittest
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Dr Paul Older Western Hospital Melbourne
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How is Anerobic Threshold Measured?
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Cardiovascular mortality in patients gt60yrs
undergoing major intrathoracic or intra-abdominal
surgery
Chest 1993 104 701-04
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Early ischaemia - becoming positive within three
minutes of onset of exercise and well before AT
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Late ischaemia - becoming positive late in
exercise and occurring around or above the AT
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Chest 1999 116 355-362
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ICU bed utilisation and mortality per 100
patients over 65 for elective major abdominal
surgery - 15 years of development of
preoperative assessment
lt1985
lt1989
lt1992
lt1994
lt1995
lt1996
lt1999
Number triaged to ICU
40(1)
100(2)
45(3)
45(3)
36(3)
29(3)
22(3)
Total bed days
600
430
260
225
152
78
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Average days in ICU
15
4.3
5.7
5.0
4.2
2.7
3.0
Non surgical mortality
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6
7
4
2
0
0.5
1) all emergency admissions following elective
surgery 2) all cases admitted to ICU electively
pre-operatively 3) elective admissions according
to triage
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Descending Aortic Velocimetry Oesophageal
Doppler?

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Intraoperative Fluid Loading guided by Doppler in
major non-cardiac (n100)
Gan et al., Anesthesiology 2002
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