Updates on Trainee Requirements at #acemws17

These are the key points for my talk at the ACEM Winter Symposium on changes to the Trainee requirements and curriculum over the last couple of years. This is based on a review of ACEM's correspondence, discussions, rumours and some wildly unfounded ideas about what might be coming ahead.

I confess that as a trainee I did not take much interest in updates, changes and college activity in general, but have seemed to become much more attuned since ceasing to be a trainee, partly through writing for the Trainee Focus section of Emergency Medicine Australasia as well as taking on a DEMT role.

Selection Into Fellowship Training

From 2018, all potential trainees must be selected into the training program, through a process cunningly called SIFT – selection into fellowship training. The aim of this process is to identify those who are likely to be suitable for, and to complete, emergency medicine training. Positive virtues, such as communication, teamwork, resilience and reflective learning will be extolled, and workforce distribution factors, such as rurality or identifying as indigenous, may also play a role. These will be identified through a structured CV, special SIFT references and an institutional reference. The exact process remains to be fully detailed, and if you’re interested in reading more, then head to this month’s issue of EMA for more discussion.

Part of this process is streamlining entry into the programme to a single entry point per year, aligned with term dates in Australia and NZ. SIFTing begins after September this year, with applications from then and through 2018 being considered for entry into the programme in 2019.

To make up for a potential delay in commencing training, applicants can now apply earlier – in PGY2 and after only 1 ED rotation. Assuming they have proven their worth in that time to be sifted in.

Site Accreditation

New accreditation guidelines were just released in June, with sites accredited for 6, 12 or 24 months differentiated mainly on levels of supervision – all are expected to provide similar standards of training and education. Some of the key requirements new in this guideline are availability of a mentoring programme, an average of 4 hours of teaching per week – with 70% attendance for trainees, the use of simulation in teaching and the provision of a dedicated trainee office and study area.

Sites will still be classified as either major referral, urban district or regional or rural. The requirement remains for a minimum of 6 months in both major referral and either urban district or regional and rural.

Make sure you are aware of how long each site is accredited for advanced training, because if you overstay this welcome, then you will not accrue any training time, but will still be required to meet all the other requirements, such as WBAs.

Provisional Training

There has not been much change to the requirements in this period, with the exception of minor changes to structured references, which must now be completed after 6 months in ED, aligned with ITAs, and kept up to date every 12 months.

3 Strikes

One of the major changes to come in: 3 strikes – a maximum of 3 attempts on each exam. This new limit commences from 2018. Any attempt of the exams prior to this are not counted. This new regulation limits trainees to 3 attempts at each exam separately – the primary written and primary viva and fellowship written and fellowship clinical.

Workplace-based assessments

The timing and review of WBAs remains confusing to many, if not all, and is based around your transition dates – when you progressed from one stage to the next and taking into account full-time or part-time training as well as interruptions of training. Reviews occur when you meet minimum time requirements to move into the next stage of training, but may take some weeks to be complete.

What’s important for trainees is to ensure you know your WBA run rate and complexity requirements for your stage. If complexity is too complex for you, there’s a new calculator on the ACEM website to assist. Your requirements are unlikely to align with your term dates, so be aware of when things are due. Make sure you do more than the minimum required.

Currently, part-time trainees are expected to complete WBAs at the same rate as full-time trainees. It’s possible in the future that requirements may be applied pro-rata for part-time trainees.

Not much has changed for WBA requirements. Shift reports are expected to be “in charge” in advanced late phase, and you have a 4 week window to select cases for CbDs (previously 2 weeks). Your WBAs must be completed by at least 2 different assessors in every 6 month period – you can’t just keep going back to the nice consultant.

Trainees enter into remediation if they are not compliant with WBA minimum requirements, which is easily avoided, but possibly also if their WBAs are interpreted that they are not up to the expected standard for their stage for training. WBA panels must make this judgement based on deidentified WBAs for trainees they don’t know. If you’ve ever read a completed WBA, you will know that it’s the comments that paint the picture. For your own feedback, and to ensure the WBA panels get the full picture, demand comprehensive comments from your assessors. Complete your Learning Needs Analysis with your DEMT – the WBA panels seek these out

Critical Care Requirements

Recent changes in CICM accreditation has seen the definition of Foundation, Basic and Advanced intensive care units, with only Basic and Advanced recognised for ACEM training. This may have some impact on trainees who would otherwise have completed terms in now Foundation units, especially in more remote areas.

ACEM has been trialling a Critical Care Accreditation Pilot – where non-CICM or RANZCA sites were accredited for ACEM training directly by ACEM. This is being followed up now with the definition of new accreditation guidelines and the development of educational activities and procedural skills logbooks that may be used in the near future for trainees to complete their critical care requirements.

Time

It has now been 12 years since ACEM introduced an absolute time limit on training, and this 12-year time limit expires in December for those grandfathered into this change. Unfortunately, there are trainees who this will affect - will the college recognise their training towards the Emergency Medicine Diploma or Certificate?

The allowances remain the same, otherwise: a maximum of 12 years, up to 5 in provisional and 10 in advanced, with allowance for 2 years of interruption of training. Some trainees may not know that they can also apply for “leave from training”, which does not count in the 12 years for prolonged absences such as parental or prolonged sick leave.

The Fellowship Exam

In preparation, you may have found there is a new Study Guide for Medical Expertise. While this is a good start, it doesn't include everything for the exam that falls in the other 7 domains of the curriculum framework. The most comprehensive and useable study guide is probably still the old syllabus handbook, circa 2012 .

There has been ongoing tweaking of the formats, with some improvements in both the written – such as improved SAQ format, a maximum mark allowing for better time management – as well as the clinical. The clinical is now fully quarantined, and runs over 3 days, with an hour of examination on each day. One day consists of 3 double stations, which will now each have 4 minutes reading (and marking) time instead of 3. The curriculum framework domains are explicitly weighted for each station – for instance 50% medical expertise, 30% communication and 20% health advocacy. This year saw 3 sittings, and in 2018 this will return to 2 sittings.

With the exam under continuous scrutiny and ongoing change, we may see some ongoing changes in format, such as a combined mark for the written components that can be passed as a whole, instead of individually. We may also see video recording of all the OSCEs to allow for review and re-assessment as required.

Reconsideration and appeals

Every now and then, a trainee might feel they’ve been wronged. So, what can you do when you think the college has got it wrong? The college has a Trainee Advocate for this purpose, and most trainees don’t know that the college also has a “Reconsideration, review and appeals” process for this purpose.

This is not an avenue to complain about bad marks, but is an option where you think your progression has been put at stake through a decision that may not be correct. You should discuss these issues with your DEMT, as well as with your state trainee rep.

What Next?

The Curriculum Framework produced from the Curriculum Revision Project is now 2 years old, and due for a review. This process is beginning at the college, and we would expect to see some changes from this roll out over the next couple of years.

As always, feel free to chip in a comment, add anything I've missed, or point out what I've got wrong!

 

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