2.1 Training concepts

2.1.1 “Spiral” learning

The training programme is based on this concept, which ensures that the basic principles learnt and understood are repeated, expanded and further elucidated as time in training progresses; this also applies to the acquisition of skills, attitudes and behaviours. There are essential units of training to which trainees return at each level, as well as specialist areas of practice that are introduced from Intermediate Level onwards. The outcome is such that mastery of the specialty to the level required to commence independent practice is achieved by the end of training.

2.1.2 Broad-based flexible training

The CCT programme is constructed so that all anaesthetists have the same essential skills. In the latter years of training flexibility is introduced so that individual career aspirations can be met by providing dedicated periods of advanced level special interest training. This also allows the specialist needs of the NHS to be met with a short lead-in time of around two years. Since all anaesthetists have a common broad-based training up to intermediate level this allows changing workforce needs to be met with a minimum of retraining.

2.1.3 Experiential Learning [See Appendix 3 – RCoA Clinical Assessment Strategy]

Much of the learning is service-based and, for its effectiveness, depends upon its context within clinical practice. Research has shown that performance improves with practice and that up to 200 iterations of a procedure may be required for the learner to approach the standard of performance demonstrated by a truly expert practitioner. Analysis of learning curves reveals that 70 to 80% of this performance is achieved after 30 iterations. There are many reasons why trainees may not be able to achieve 30 performances of a technique and there is no expectation that all elements of the curriculum will be learned to that level of skill. The RCoA WPBA system does not require performance to this level, except those related to the advanced level units of training chosen by the individual trainee. The need for repetitions in training is an important determinant of the duration of training. The suggested length of placements in the training programme is such that there is reasonable opportunity for trainees to become expert in the key competencies on which the safety of practice depends at CCT.

2.1.4 Role of intensive care medicine in anaesthesia

Training in intensive care medicine [ICM] is an integral part of anaesthesia training. The skills learned in managing critically ill patients in the intensive care environment are transferable and contribute to the skills required in managing patients across the perioperative period. The development of these skills and knowledge directly contribute to patient safety and patient care outcomes. There are three types of roles anaesthetists may aspire to for intensive care practice. Each defined role includes the level of intensive care qualifications/experience recommended before taking the role.

2.1.5 Common competencies of medical practice required by all doctors

The trainee must also develop the general professional knowledge, skills, attitudes and behaviours required of all doctors. It is the view of the College that they should be developed and followed throughout practice, both during training and post-CCT. Thus, there are no changes to these competencies over the years of training. These competencies are also embedded in the clinical units of training at all levels. Trainees’ achievements in each domain should be documented when each unit of training is completed. Thirteen domains have been identified covering professionalism and common competencies (Annex A). These are as follows:

• Domain 1: Professional attitudes and behaviours
• Domain 2: Clinical Practice
• Domain 3: Team working
• Domain 4: Leadership
• Domain 5: Innovation
• Domain 6: Management
• Domain 7: Education
• Domain 8: Safety in Clinical Practice
• Domain 9: Medical ethics and confidentiality
• Domain 10: Relationships with patients
• Domain 11: Legal framework for practice
• Domain 12: Information Technology
• Domain 13: Alcohol and other drugs

2.1.6 Human factors in clinical practice

The curriculum requires trainees to demonstrate comprehensive knowledge of many aspects of managing safety. Human factors theory focuses on a range of topics associated with human abilities, behaviours and limitations in the context of workplace safety. Knowledge of these factors can be applied to influence the design of systems, tasks and equipment to make allowances for human capability in complex working environments. Human factors theory can be translated into the non-technical skills [NTS], which complement individual technical skills to facilitate safe and efficient performance of tasks. NTS are cognitive, social and personal skills such as:

• Effective communication
• Team working
• Leadership
• Decision making
• Situation awareness
• Stress management

Good practitioners employ these skills to achieve consistently high performance and they are accepted as intrinsic to safe clinical practice. This curriculum recognises the importance of human factors by incorporating these into training and assessment. The Anaesthetic Non-Technical Skills [ANTS] taxonomy has been developed for assessing this area of practice [http://www.abdn.ac.uk/iprc/ants].

2.1.7 Teaching and Training; Academic and Research; Management

These are considered essential elements of the training programme. Trainees require a clear understanding of the principles of adult learning, academic enquiry and healthcare management and there are clear competencies that develop these subjects throughout the training programme. The opportunity to undertake further training in these disciplines is provided within Advanced training for trainees with a specific interest [Annex G]. More guidance is given on this in section 10.2.8.

2.2 Training environments

The training of anaesthetists will occur in UK posts and programmes approved by the GMC, or in other posts and programmes for which prospective approval has been given. Departments in which training occurs must comply with the regulations and recommendations of the relevant national Departments of Health, GMC, the RCoA, Faculty of Pain Medicine [FPMRCoA] and the Faculty of Intensive Care Medicine [FICM]. From time to time, the RCoA, FPMRCoA, FICM and AAGBI issue guidance on standards of practice, which must be adhered to by departments in which training occurs.²

2.3 Trainers

In order to ensure patient safety, consultants and trainees in anaesthesia work more closely together in clinical practice than is the case in most other specialties. Anaesthetists are very risk aware and strict supervision of learners is embedded in their practice. See Section 5 for further details on supervision. Doctors responsible for training have to comply with the GMC standards for specialty training³ .

2.3.1 Training in the NHS

The GMC is responsible for approving posts and programmes for training. Clinical training is ordinarily delivered in NHS hospitals by consultants, staff and associate specialist [SAS] grades,^{4, 5} and by senior trainees. Senior educators/clinicians with responsibility for education and training are joint appointments by the College and Deanery/LETB. Trainers are supported by RAs and CTs appointed with input from the Deanery/LETB and hospital management by the RCoA, FPM or the FICM and by educational supervisors appointed locally.

2.3.2 Trainees as trainers

Trainees should learn to supervise more junior trainees as they progress through their training. Senior trainees should have the opportunity to contribute to the organisation and delivery of formal training under the supervision of the College Tutor or other designated trainers as identified in this curriculum Section 5. 2.3.3 Criteria for appointment as a trainer/assessor The following criteria should be met for a consultant, locum consultant, staff and associate specialist, and trainee to act as a trainer/ assessor:

• Successful completion of a trainers course [eg train the trainers];
• Understanding of the structure of the training programme and content of the curriculum;
• Aptitude to teach;
• Regular clinical commitment;
• Evidence of recent CPD relevant to current clinical practice;
• Annual assessment or appraisal by a consultant anaesthetist;
• Willingness to complete the necessary training documentation mandated in the curriculum and by the School of Anaesthesia;
• Willingness to provide a post training session debrief including feedback on performance; and
• Ability to detect the failing trainee
• Successfully completed a course on assessment and assessment tools;
• Aptitude for assessment;
• Understanding of the assessment system described in the curriculum; and
• Willingness to assess the trainee and complete the necessary documentation including a post assessment debrief.

It is the Trust / School (who pay the Educational Supervisors) responsibility to ensure that trainers and assessors meet the required criteria. CTs will nominate and supervise suitable Educational Supervisors. In order to become an approved, recognised trainer, trainers must meet the GMC criteria.⁶

2.4 Delivery of the training programme

A minimum of three supervised sessions per week [averaged over three to six months] is required to ensure sufficient workplace based learning to allow most trainees to progress to CCT within the seven year indicative length of the programme; this figure is based on many years of experience. It is accepted that there may be variation from week to week depending on local work patterns and the structure of individual school programmes of training.

To ensure patient safety, trainees new to the specialty must, at all times, be directly supervised until they have passed the Initial Assessment of Competence [IAC] (see Section 5). This is also the case for those new to specialist areas of practice. These concentrated periods of supervision are essential to ensure that trainees complete all the required core clinical learning outcomes in a very full programme. Following this, the appropriate level of supervision for the trainee’s level and competence should be provided.

It is important to ensure that supervised sessions have relevance to the unit(s) of training (and Level) that individual trainees are undertaking at the time; the concept of a ‘balanced programme of training’ is essential. It is therefore acceptable, for example, to count two accompanied sessions in ITU, coinciding with daytime service for ITU, if the trainee is on a dedicated ICM block. It is not appropriate if they are providing service cover for ICM for the day whilst undertaking an anaesthetic unit of training, as the supervised sessions should be in this area of practice.

2.5 Out of hours commitments

Out of hours work for trainees largely involves providing services for emergencies and, compared with elective work, makes different demands on the anaesthetist. There are several reasons for trainees to undertake out of hours work. It provides:

• The opportunity to experience and develop clinical decision making, with reduced resources, under distant supervision
• The opportunity to learn when to seek advice and appreciate that close clinical supervision is required when learning new aspects of emergency work
• A reflection of professional anaesthetic practice, as in most hospitals patients are admitted 24 hours a day, seven days a week; there is thus a service commitment

Occasionally there may be a unit of training where out of hours work is not required; this will be the exception. For units of training where out of hours work is required [the majority], trainees should not normally work more than 7 nights in an 8 week period to ensure that they can meet the many training outcomes that are gained during normal working hours, in addition to those gained out of hours. The College recognises that there are occasions when additional out of hours work is required due to local circumstances; when this occurs, it should only be for short periods otherwise the trainee will require extended training time to ensure the core clinical learning outcomes are met. Local trainers, in conjunction with their Clinical Directors [CD], must recognise this consequence of excessive out of hours commitments. Finally, it is important to ensure that any new aspects of emergency work are undertaken initially with close clinical supervision.

For trainees unable to undertake out of hours work due to illness or other debilitating circumstances, the College Tutor, RA, TPD and Chair of the Training Committee will determine whether it is possible to obtain all the essential core clinical learning outcomes and whether extra training time is required. This may involve extending the period of training for a specific unit[s] and/or the whole programme. Trainees are advised to discuss the potential consequences of inability to perform out of hours work as soon as practicable, as it may have a major impact on the training programme leading to the award of a CCT.

2.6 Less than full-time [LTFT] trainees

After appointment any trainee, with Deanery/LETB agreed eligibility, can request to train less than full time. The training programme will then be delivered on a pro rata basis. Each region has a LTFT adviser who works with the RA and the local Deanery/LETB to ensure that the needs of those trainees are met. General advice on LTFT is contained in the “Gold Guide”⁷ . In addition, one of the College Bernard Johnson Advisers provides strategic advice to the RCoA on the needs of part time trainees and can be contacted via training@rcoa.ac.uk.

The European Medical Directive states that: “Member States may authorise part-time training under conditions laid down by the competent authorities; those authorities shall ensure that the overall duration, level and quality of training is not lower than that of continuous full-time training.”⁸

This is interpreted to mean that LTFT trainees should, pro rata, undertake the same out-of-hours work as full-time trainees, including weekend duties. In October 2011, the General Medical Council confirmed the minimum requirement for LTFT should be 50%. ⁹

2.7 Schools of Anaesthesia

Schools of Anaesthesia are responsible, on behalf of the Deanery/LETB, for the delivery of a GMC approved programme of postgraduate education in anaesthesia, intensive care and pain medicine. There may be separate Schools for Acute Care Common Stem [ACCS] training. The School should provide educational leadership and governance, ensuring appropriate structures are in place to deliver training to the standards required by the GMC.

All hospitals in the UK that provide training belong to a School. It is important to note that the Schools of Anaesthesia are not a homogenous group and therefore the Curriculum permits flexibility to allow local organisation of training.

There are several different leadership/management roles in a School of Anaesthesia. A particular School may or may not have all of these areas of specific responsibility;

• Head of School [HoS]: appointed by the Deanery/LETB with RCoA input
• Regional Adviser [RA]: appointed by the College with Deanery/LETB input.
• RAs for ICM [RAICM] and Pain Medicine [RAPM] by the Faculty of Intensive Care Medicine or Faculty of Pain Medicine with Deanery/LETB input
• Deputy Regional Advisors [DRAs] to be appointed by the College with Deanery/LETB input
• Training Programme Director [TPD]: Deanery/LETB appointment
  • TPDs appointed for ICM and ACCS
  • Deputy TPDs responsible for a specific part of the anaesthetic training programme e.g. core trainees
• College Tutors: within each Trust; joint appointment by College, Trust and Deanery/LETB
• Faculty Tutors for ICM
• Representation from the Faculty of Pain Medicine
• Less Than Fulltime Training Adviser

The number of hospitals and tertiary specialist centres which together constitute a School of Anaesthesia varies across the UK. Occasionally a Deanery/LETB may divide training by geography e.g. North and South Schools, for administrative and logistical purposes.

Together, hospitals within a School can normally provide all the essential units of training required to achieve a CCT in Anaesthetics. District general hospitals can offer a wide range of experience and training, whilst the more specialist area of anaesthesia for cardiac, thoracic, neuro and paediatric surgery may take place in a tertiary referral centre. Occasionally secondments are required outside the School in order to obtain these specialist areas of training. Single speciality hospitals may complement the overall provision of training within a particular School.

The TPD must organise rotations in such a way that all trainees are exposed to all the essential units of the training programme at an appropriate stage to allow the attainment of competencies and completion of core clinical learning outcomes and progression towards the CCT.

Schools may have their own documentation advising their trainees what is required to progress through the curriculum. Delivery of training is the responsibility of the School. The curriculum, its assessment and the e-portfolio are the responsibility of the RCoA.

Schools are also responsible for ensuring the ARCP occurs and assuring the quality of training. Schools are involved in approving study leave and providing access to relevant educational courses for their own trainees.

More information about individual Schools can be obtained from their local Deanery/LETB or from School websites.

2.8 Speciality Advisory Committees

The majority of Deaneries/LETBs have Speciality Advisory Committees [sometimes known as Training Committees]. The attendance should include the RA and the College Tutor[s] from each hospital, as well as representation from the School and trainee body. Duties include overseeing the training programme, ensuring standards of training are maintained and resolving any local training issues.

2.9 Responsibility for training in the workplace

The responsibility for the organisation, monitoring and efficacy of training and assessment is shared by a variety of authorities:

• The GMC is responsible for approving programmes of training
• The RCoA is responsible for:
  • Advising the GMC on the competencies/learning outcomes in training
  • Advising the Postgraduate Deans on the arrangements for organising and monitoring the inservice training provided by Schools of Anaesthesia and hospitals
  • Funding the Bernard Johnson Advisers who provide advice on equality and diversity issues within training programmes
  • Evaluating the training of individual trainees and recommending them to the GMC for the award of CCTs
• The Postgraduate Dean is responsible:
  • To the GMC for the quality management of the training programme
  • For the overall training arrangements in each Trust. The Clinical Tutor/Director of Medical Education acts as the Dean’s officer within the trust and has overall responsibility for the educational environment
  • For ensuring that the ARCP process is organised correctly
• Schools of Anaesthesia in conjunction with the local Specialty Training Committee/Specialty Board are responsible for:
  • The administrative organisation of trainee placements/rotations in the training programme
  • Monitoring the training programme
  • The administrative organisation of ARCPs
  • Working with CDs to ensure satisfactory local arrangements are in place to ensure in-service training is delivered in accordance with the principles adopted by the Department of Health [in regard to rota compliance], the GMC, the RCoA and the Postgraduate Dean
• TPDs organise the rotations to ensure that all units of training are covered
• RAs are responsible for representing the policies and views of the College in all relevant matters within their region
• College Tutors are responsible, ultimately, for the overall anaesthetic training and assessment arrangements in their hospitals¹⁰, working in conjunction with the individual educational supervisors.
• Educational Supervisor is defined by the GMC as a trainer who is appropriately trained to be responsible for the overall supervision and management of a specified trainee’s educational progress during a training placement or series of placements. The educational supervisor is responsible for the trainee’s educational agreement.¹¹
• Clinical Supervisors are trainers who are appropriately trained to be responsible for overseeing a specified trainee’s clinical work and providing constructive feedback during a training placement; in anaesthetic training, Clinical Supervisors will normally be the lead for specific units of training. Some training schemes appoint an Educational Supervisor for each placement; if this is in a hospital that only delivers one unit of training, the roles of Clinical and Educational Supervisor may be merged¹² .
• Consultant/SAS trainers: All consultants/SAS anaesthetists who have any contact with trainees [which includes providing senior support and cover for out of hours duties] have a responsibility for providing appropriate training, supervision and assessment. They should comply with the Deanery/LETB requirements.

2.10 Accommodation for training and trainees

Any hospital with trainees must have appropriate accommodation to support training and education; this may be in the Department of Anaesthesia or elsewhere in the hospital e.g. the Postgraduate Teaching Centre. This accommodation should include:

• A focal point for the anaesthetic staff to meet so that effective service and training can be co-ordinated and optimal opportunities provided for gaining experience and teaching
• Adequate accommodation for trainers and teachers in which to prepare their work
• A private area where confidential activities such as assessment via the e-Portfolio, appraisal, counselling and mentoring can occur
• A reference library where trainees have ready access to bench books [or an electronic equivalent] and where they can access information, including electronic resources, at any time
• Access for trainees to IT equipment such that they can carry out basic tasks on a computer, including the preparation of audio-visual presentations; access to the internet is recognised as an essential adjunct to learning and access to the trainee e-Portfolio
• A suitably equipped teaching area and a private study area
• An appropriate rest area whilst on shifts

2.11 Equipment and safety guidance

Anaesthesia is high risk and measures to help ensure safe practice have been incorporated into the fabric of anaesthesia, which are emphasised to each new generation of anaesthetists. Specific competencies relating to patient safety are included in every section of the anaesthesia learning. There is therefore no specific section of learning devoted to safety.

Trainees should keep abreast of RCoA and AAGBI guidance on safety issues.

• Monitoring standards: Trainees should not be required to deliver anaesthesia without using monitoring equipment that complies with the recommended minimum monitoring standard current at that time. The most recent standards are those defined in: Recommendations for Standards of Monitoring during Anaesthesia and Recovery, 4 th Edition 2007, Association of Anaesthetists of Great Britain and Ireland Guidelines for the Provision of Anaesthetic Services (GPAS), Royal College of Anaesthetists
• Skilled Assistance: Trainees must have dedicated qualified assistance wherever anaesthesia is administered as defined in: The Anaesthesia Team 3, 2010, Association of Anaesthetists of Great Britain and Ireland.

2.11.1 Key protocols

It is recommended that key protocols and guidelines, including amongst others those for management of anaphylaxis, malignant hyperthermia, airway management and resuscitation, should be displayed or be immediately available in all locations where anaesthesia is delivered (AAGBI, Resuscitation Council and RCoA GPAS).

2.11.2 Simulating critical incidents and equipment failure

It is a necessary part of trainees’ development that they should gain the confidence to handle critical incidents and equipment failure. Trainees should be made aware that in the event of a mishap it should not be presumed that the equipment is in the same state as when checked before the start of the list. In no circumstances is it acceptable for an anaesthetist to interfere with an anaesthetic machine during a procedure with an anaesthetised patient for the sole purpose of testing the reactions of a trainee. Training for these eventualities is appropriate in simulated situations, without a patient being present, or in verbal discussion.