Transcript Document

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
Centre for Anaesthesia UCL
USA and UK
“ Two Great
Countries Separated
by a Common
Language”
Oscar Wilde
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?
Marathon des Sables
•Extreme endurance eventseveral hours/ day
•Thermal challenge
•Fluid loss
•Electrolyte imbalance
•Acute inflammatory response
Marathon des Tables
•Extreme endurance eventseveral hours / days
•Thermal challenge
•Fluid loss
•Electrolyte imbalance
•Acute inflammatory response
Anaesthesia in Europe (UK)
• How convince Anesthesiologists to go
outside the O.R?
• Is it all economics?
YES – BUT!
Anesthesia Outside the OR?
• Critical Care – 90% Anesthetists
• Pain – Acute and Chronic – 95%
Anesthetists
• Pre-op evaluation
• Critical Care Outreach
• Management
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
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
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?
Training changes in last
decade – 10 yrs ago
• Med Student
• PRHO (no debts)
• SHO (non-anesthesia)
• Reg. (3 exams FRCA)
• Research (MD/PhD)
• Senior Registrar
Consultant
5-6 yr
1 yr
1-4yr
4 yr
1-3 yr
4 yr
96 hrs pre week – “undertime”
Funding in UK?
• National Health
Service
– Service delivery
by senior trainees
(post-fellowship)
– Consultant led
• Private Practice
– Consultant
delivered
Training changes in last
decade –10 years ago
• PRHO
• SHO (non-anesthesia)
• SHO (Anesthesia)
• Reg. (3 exams FRCA)
• Research (MD/PhD)
• Senior Registrar
Consultant
1 yr
1-4yr
2 yr
4 yr
1-3 yr
4 yr
96 hrs pre week – “undertime”
Training changes in last
decade - now
• PRHO (Modest Debt!)
• SHO
• SpR
Consultant
1 yr
1-4yr
5 yr
48 hrs pre week – “OVERTIME!”
European Working Time Directive
EU – equivalence in training
Funding in UK?
• National Health
Service
• Private Practice
– Consultant
delivered
– Trainees
– Consultant
delivered (48 h
working week)
R.O.W
?
N.P.A
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?
Non-Physician Anaestheitists
in UK
• Can only work under Physicians
• Same as SHO (competent – not “postfellowship” – 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?)
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
Training?
• Whats new in Europe
(UK)?
• DR Judith Hulf – Vice
President R.C.A.
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
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.”
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
STA
* Independent
PMETB
* 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
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?
PMETB and the CCT
• CCT=CCST
• 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”
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
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!
Medical school
Two Year Foundation Programme
Specialist or GP training
Provisional
Registration
GMC
Full
Registration
GMC
F2 Curriculum
Case mix suited to be taught by;
Critical Care
A&E
Acute Medicine
Anaesthesia
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
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
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”
MMC – Possible Foundation
Competency Based Programmes
Accreditation
Accreditation
Competency Threshold 2
Level 2
Accredited
General
Practice
Training
Programmes
Accredited
Specialist
Training
Programmes
Competency Threshold 1
Level 1
ST Non
Programme
Posts
Foundation Year 2
Foundation Year 1
ST
ESA
(Reformed SAS Grades)
Accredited
Specialist (CCT)
Accredited
GP (CCT)
Enhanced
Service
Appointments
Seamless specialty training
•Direct Path
•Broad-based Path - Common stem
programme
ST1
common stem programmes
ICM
surgery
neuro
sciences
A&E
Acute
medicine
Anaes
thesia
ICM,acute medicine,
anaesthesia,A&E
non
acute
medicine
FY2
FY1
Oct 2005
GP
paeds
community
medicine
ST1
and beyond
Anaesthesia
ICM,acute medicine,
anaesthesia,A&E
FY2
FY1
Oct 2005
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
Keys to Success
Manpower planning
Managing competency-based training
Stopping continual change
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
Article 14
• Country of origin is immaterial
• Considers training and experience
from anywhere
–Ratio T:E is unclear
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
145
Have to have done training abroad to
fit into this category
( to stop UK trainees taking this route)
Nuffield Chair at Oxford
University
“Any fool can give an
Anaesthetic”
“Yes, that’s what
worries me!”
Anaesthetic Grant
Application
Dear Sirs:
Despite there never having been any meaningful
investment in Anaesthetic research, Anaesthetics always
work and are incredibly safe (mortality < 1:100,000).
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
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
Hospital Mortality (%) following
Major Surgery and Intensive Care
in UK 7/99 TO 01/00
40
ICNARC
35
30
25
UK (n=22,059)
UCLH (n=288)
20
15
10
5
0
Overall
Elective
Scheduled Emergency
Patients in Hospital with Morbidity
Following Major Surgery at UCLH
50
45
40
35
30
25
20
15
10
5
0
Morbid (%) n = 183
Day 5
Day 8
Day 15
Survival of The Fittest
Dr Paul Older:
Western Hospital Melbourne
How is Anerobic Threshold
Measured?
Cardiovascular mortality in patients >60yrs
undergoing major intrathoracic or intraabdominal surgery
Cardiovascular mortality and anaerobic threshold
90
80
n = 184
70
'n'
60
50
survivors
40
non survivors
30
20
10
0
<8
8-10.9
11-13.9
Anaerobic threshold (ml/min/kg)
Chest 1993 104: 701-04
>=14
Early ischaemia - becoming positive within three
minutes of onset of exercise and well before AT
‘AT’ 600 ml/min 9.7 ml/min/kg
This is moderate cardiac failure
but note early onset of ST depression
Late ischaemia - becoming positive late in
exercise and occurring around or above the AT
‘AT’ 1160 ml/min : 16.5 ml/min/kg
No cardiac failure
note onset of ST depression
Major surgery
(i) Age > 60 yrs. (n =476)
(ii) Age < 60 yrs. known ischemic heart
disease or cardiac failure (n =72)
C.P.X.
AT <11ml/min/kg
or aortic or
oesophageal surgery
AT >11 ml/min/kg
with myocardial
ischemia or Ve/VO2 >
35 on CPX
AT > 11 ml/min/kg.
no myocardial
ischemia and
Ve/VO2 < 35 on
CPX
ICU
28% (n =153)
HDU
21% (n=115)
Ward
51% (n=280)
CVS mortality
CVS mortality
CVS mortality
4.6% (n=7)
1.7% (n=2)
0%
Definition of abbreviations: AT = anaerobic threshold, Ve/VO2 = ventilatory equivalent for oxygen,
ICU = intensive care unit, HDU = high dependency unit, CVS = cardiovascular,
CPX = cardiopulmonary exercise test
Chest 1999 116: 355-
ICU bed utilisation and mortality per 100 patients
over 65 for elective major abdominal surgery
- 15 years of development of preoperative
assessment
<1985 <1989 <1992 <1994 <1995 <1996 <1999
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
66
Average days in ICU
15
4.3
5.7
5.0
4.2
2.7
3.0
Non surgical mortality
19
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
Descending Aortic Velocimetry:
Oesophageal Doppler?
Intraoperative Fluid Loading
guided by Doppler in major noncardiac (n=100)
Colloid
Control
Protocol
P value
0.9
2.5
15
13
75
53
0.03
54
32
0.01
(mL/kg/h)
Crystalloid
(mL/kg/h)
Hospital Stay
(Days)
Tolerate Food
(Days)
Gan et al., Anesthesiology 2002